Diabetes and your mouth

Because diabetes impacts blood sugar levels, it has the potential to touch every system in your body, your mouth included. When left uncontrolled, diabetes can cause myriad oral health problems: gum disease, increased incidence of tooth decay, delayed healing, dry mouth, infection, benign lesions, neurosensory disturbances, and the list goes on. As the number of Americans with diabetes has climbed to nearly 29.1 million — just under 10 percent of the U.S. population — it’s more important than ever for dentists to keep a well-trained eye on signs of the systemic condition’s oral manifestations.

It’s something that Brent Hutson, D.D.S., M.S., encounters nearly every day as an associate professor in restorative sciences at Texas A&M University Baylor College of Dentistry. His role is unique; he spends one day a week in private practice, treating medically complex patients at the Charles A. Sammons Cancer Center, located just down the street from the dental school. The remainder of the week he supervises dental students in TAMBCD’s clinics. By conservative estimates, Hutson says approximately 50 percent of the patient base he treats at the Sammons Center is diabetic.

After practicing more than 20 years, he has the vantage point of recalling how patient care has changed since his days as a TAMBCD dental student.

“I graduated in 1993 and distinctly remember only having two of my assigned patients taking any medication on a regular basis, and did not have a single diabetic patient,” Hutson says. “Today as I work with students in the clinic, nearly all of our patients are taking multiple medications.”

As diabetes reaches endemic proportions, more people than ever are touched by the condition on a personal level, and Hutson is no exception. His now 87-year-old father was diagnosed with Type 2 diabetes 10 years ago.

“I have personally witnessed his disease progress and have worked with him to manage the full spectrum of his health,” Hutson says. “Although well-educated on diabetes, I completely underestimated how difficult this disease would be for my father.”

Chairside considerations and long-term management

For Hutson and TAMBCD students and faculty, managing this condition begins the moment a patient sits in the dental chair. A blood glucose measurement, taken with a glucometer, is a high priority at each appointment. This test is considered a standard of care, but it reveals only current blood glucose levels. Prior to sedation or operative procedures, an A1C test is analyzed to gauge a patient’s blood glucose levels over several months. Special care is taken to learn about recent eating and medication habits in efforts to prevent hypoglycemia — low blood sugar — during care. While elevated blood sugar levels are a hallmark of diabetes, onset of related symptoms (headaches, blurred vision, frequent urination, fatigue, nausea) tends to develop over a period of several days or weeks, and not within a matter of minutes, as is the case with hypoglycemia.

Chronic management of diabetes requires dedication on the part of dentist and patient. In addition to patient education and preventive measures, Hutson cites the one tool a dentist can utilize to best prevent oral manifestations of diabetes.

“The most important intervention we can offer is frequent recalls, especially in the poorly controlled diabetic,” says Hutson. “This affords an opportunity to re-evaluate and address dental issues as they arise.”

Among the most common therapeutic measures Hutson prescribes to diabetic patients for at-home intervention: products to treat xerostomia — dry mouth — and smooth surface cavities — decay that occurs on flat tooth surfaces. Impeccable oral hygiene and compliance to prescribed preventive measures is imperative to managing a diabetes-related oral condition.

In some cases, problems can be avoided entirely.

“The most important factor in these trends is how well the patient is controlling blood glucose levels,” says Hutson. “A well-controlled diabetic may show no oral manifestations of the disease.” And what about patients whose diabetes is poorly controlled? “The presentation of diabetes-related oral conditions will increase over time,” he says.

Factoring diabetes into community care

According to the 2014 National Diabetes Statistics Report, of the estimated 29.1 million cases of diabetes in the U.S., 8.1 million of them are undiagnosed. Perhaps just as eye-opening is the fact that 86 million Americans age 20 and older have prediabetes, a condition marked by blood glucose levels that are higher than normal, just not high enough to warrant a diabetes classification.

Early detection plays a key role in combating diabetes and, as such, in January 2016 TAMBCD launched a pilot program at one of its community training sites, North Dallas Shared Ministries. Dental assistants and dental students at the clinic screen for diabetes and administer a glucometer test for walk-in patients. Results are cross-checked with bloodwork taken by medical residents with UT Southwestern, the dental school’s community partner at North Dallas Shared Ministries. At-risk patients will receive referrals to UT Southwestern, and their total health will be tracked over time so that students and faculty from both institutions can gauge outcomes.

The program could result in even more diabetes diagnoses. Of the 3,000 patients TAMBCD students treated in 2015 at North Dallas Shared Ministries, approximately 600 had chronic medical conditions, diabetes among them. Paul Hoffmann, administrative director of extramural clinics at the dental school, says he expects to see up to 900 new diagnoses as a result of the increased screening efforts.

A two-way street

The physician-dentist collaboration occurring at North Dallas Shared Ministries is a snapshot of changes in the health care landscape when it comes to detecting diabetes in its early stages.

“As physicians, we are very excited to collaborate with dentists on screening patients for diabetes,” says Lydia Best, M.D., medical director of the Diabetes Health and Wellness Institute, affiliated with Baylor Scott and White Health and located near Dallas’ Fair Park.

“Currently there is some encouragement from different medical and dental authorities for dentists to perform office testing to identify and refer patients with diabetes. Likewise, primary care providers are encouraged to screen for periodontal disease and refer patients to the dentist and hygienist.”

As a part of routine patient wellness visits at the diabetes center, Best says physicians check for signs of oral cancer, severe tooth decay, periodontal disease and acute infection.

Hutson’s role treating cancer patients takes the interdisciplinary collaboration one step further, with frequent early morning and evening phone calls to his patients’ oncologists and primary care providers.

“The days of dental health care providers compartmentalizing their expertise to dental disease have long passed,” says Hutson. “As the overall medical complexity of the general population changes, so must the dental clinician’s ability to understand implications this change brings to the delivery of safe and effective dental care.”